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Global Fund Observer


Issue 237: 18 February 2014

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1. NEWS: Volatile South Sudan presents challenges to Global Fund assistance

Conflict, prevailing insecurity and wholesale destitution of a vulnerable population in the world’s youngest country could provide instrumental lessons for the Global Fund’s future response and work in fragile states.

2. NEWS: South Sudan’s malaria program sees challenges – and not just due to conflict

In South Sudan, challenges to program implementation are legion, and only compounded by conflict.

3. NEWS: Integration of TB and HIV programs in high burden countries both necessary and beneficial, experts say

Integrating TB and HIV programs in countries with high rates of TB-HIV co-infection is necessary and will produce benefits, but there will be some challenges in making it happen, experts say.

4. NEWS: Malawi’s CCM adds new TB voices ahead of integrated concept note development

The requirement that Malawi submit an integrated concept note for HIV and TB under the new funding model should boost the southern African country’s ability to bring the disease under control.

5. NEWS: HIV spreading in Asia, including among Global Fund High Impact countries

A new UNAIDS report warns that progress in curbing HIV infections in Asia is at risk of stalling without better targeting of prevention programs to key populations.

6. NEWS: For its HIV grant, El Salvador chooses sub-recipients representing key populations

New funding model early-applicant El Salvador has chosen sub-recipients representing key populations for its $23.1 million HIV grant.

7. NEWS: Niger close to procurement plan for malaria response ahead of June rains

Niger is in its final stages of procuring nets and first-line malaria treatment under an $18.1 million transitional funding request, in time for the rainy season beginning in June.

8. NEWS: Anti-gay bill in Uganda could have disastrous public health implications

Public health actors in Uganda are warning about catastrophic consequences for HIV infection rates should President Yoweri Museveni sign into law a sweeping anti-homosexuality bill.

See section near the end of this newsletter listing additional articles available on GFO Live.

1. NEWS: Volatile South Sudan presents challenges to Global Fund assistance

The Fund and its partners grapple with implementing development programs in a country paralyzed by insecurity

Since mid-December 2013, ethnic clashes in South Sudan have displaced about a half-million people and sent more than 100,000 fleeing across borders seeking refuge. That insecurity, and the attendant mobility of the population, has interrupted a number of development programs, including several that are receiving financial support from the Global Fund.

The Global Fund and its principal recipients, the UN Development Program and Population Services International, are among legions of international organizations working in South Sudan since the framework for its independence was established in the 2005 Comprehensive Peace Agreement, responding to the considerable unmet needs in a country with only a basic public infrastructure.

Recent clashes have ground to a halt the slow transition South Sudan was pursuing away from emergency humanitarian assistance towards a more stable development scenario.

PSI program manager Farhana Zuberi told Aidspan in late January that overall, the recent conflict has had only a limited impact on the arrival into South Sudan of commodities. Malaria commodities were in country prior to the outbreak of the crisis, and there were only “one or two weeks of delays when the Juba airport was closed [from 16-19 December]” in deliveries of HIV-related supplies.

Road deliveries, however, have been more severely compromised. Three states – Jonglei, Unity and Upper Nile – remain inaccessible due to security concerns, according to Francis Yatta, the coordinator of the country coordination mechanism (CCM) secretariat.

“The southern route between Juba and Yei is equally risky for trucks because of armed bandits,” he told Aidspan during a January visit to the capital, Juba.

A city that in November was bristling with international staff from NGOs and diplomatic missions, Juba is now almost deserted due to insecurity. This has caused many South Sudanese partner organizations to close their doors temporarily and evacuate the city of their employees, leaving a lot of the programs unstaffed and phones unanswered. According to the Global Fund, management of programs it supports has continued, with the UN Development Program maintaining a complement of staff to support HIV activities and the PSI management unit in close contact from Nairobi.

Yet in repeated comments to Aidspan, South Sudanese health ministry officials carrying out malaria and HIV response campaigns and activities spoke of their frustrations about what they termed a lack of response and reaction from the Global Fund’s in-country partners to the humanitarian emergency that was unfolding.

In particular they cited the impossibility of reallocating existing funds to emerging needs, such as assessments in the crowded camps for the internally displaced, where an estimated one-third of new arrivals are showing up with malaria.

Pleas for greater flexibility in programs that could receive Global Fund support were aired again at a 31 January meeting in Nairobi, at which representatives from the Global Fund met with the PRs, the CCM, health ministry officials and other technical partners to develop a strategic response to the crisis.

The meetings, to which technical partners were invited as well as other humanitarian actors in South Sudan, was an effort to collaboratively develop strategies on how to deal with the issues emerging from the crisis and how to be most effective in service delivery despite the prevailing insecurity. Marion Gleixner, the portfolio manager for South Sudan for the Fund also called the meetings important for deliberations on contingency measures to be implemented in case there was further deterioration of the security situation.

“If there is something needed in the field, we will figure out a way to get it there. But we also need to make sure that we maintain our commitments to our existing programs, to our routine work,” she said.

Those “routine commitments” present their own challenges even at the best of times. The rainy season renders the anemic network of mostly dirt roads in South Sudan virtually impassable, leaving only a four-month window of opportunity for commodity and equipment distribution outside the capital.

“It prevents us from developing an efficient surveillance system around the country,” noted Yatta. “At the health facility level, we have to continuously remind personnel to remain vigilant or risk stockouts of critical medicines.”

Such vigilance takes time and requires a more established and mature health infrastructure. And while South Sudan has made great strides in establishing a health management information system, there are still yawning gaps in data collection as well as in administration of the system as a whole. It is for that reason that PRs for the Global Fund remain international organizations.

The government has signaled its intention to take over PR responsibilities in coming grant proposals, an announcement that was anticipated by the current PRs and an eventuality that has driven the inclusion of capacity-building and skills transfers into all of the Fund’s grants that the CCM chair, Dr Riek Lul said were critical “to overcome the huge gaps and challenges we have, in order to achieve harmonization.”

 “We are not wedded to being PRs for life,” noted PSI’s Zuberi.

The growing pains and lessons experienced by South Sudan are to be expected for a country that has yet to celebrate its third birthday. But they also present a unique opportunity for the Global Fund to review its engagement with fragile states and how best to navigate an evolving security environment while ensuring service delivery and support.

Such a review is currently under way. In his November address to the Global Fund Board, the Secretariat’s executive director, Mark Dybul, referenced an ongoing evaluation by the Technical Evaluation Reference Group of the Fund’s engagement in fragile states (see framing document here). Aidspan understands that South Sudan will be included as one of three case studies contained in the review, which is expected to be made public in 2014.

Read the article in French. Lire l'article original en français.

[This article was first posted on GFO Live on 18 February 2014.]

To comment on this article, click here.



2. NEWS: South Sudan’s malaria program sees challenges – and not just due to conflict

Difficult coordination and a lack of flexibility are chief complaints of the new nation’s health officials

The town of Minkammen, on the banks of the White Nile, has been inundated with thousands of South Sudanese fleeing the conflict pitting rebel against government fighters upstream.

Under the cover of darkness, they pack boats and ferries to sail the 26km away from the violence in the Bor region, leaving everything they own behind. But what they do carry into the packed camps of internally displaced people is malaria p. Falciparum, according to the National Malaria Control Program’s director, Harriet Akello Pasquale.

An estimated 75,000 people have crowded into makeshift informal settlements in Minkammen since the fighting erupted in late December 2013, many families having to make do with only a thin tree for shade. But even though it is possible to hang a mosquito net from a tree, there simply aren’t enough to go around.

The same desperate scenario repeats itself in camps around the capital, Juba, where some 30,000 people are looking to the United Nations peacekeepers to keep them, if not safe, then at least beyond the reach of the fighters and the looters.

There, too, the incidence of malaria is high – abnormally high for the dry season and bringing with it an outsized death toll that worries Akello Pasquale about the imminent rains and the potential calamities they will bring with them.

“We are not at all prepared to confront the emergency”, she told Aidspan during a January visit to Juba. “It is now that we must act but we do not have the funds to carry out evaluations, our international partners [including principal recipient Population Services International] have evacuated the country and all decision-making has been paralyzed. Communication is also hard at a distance. The system is just not flexible enough.”

But while acknowledging  that there are challenges inherent in modifying or adapting existing development programs to a straitened emergency context, PSI took pains to explain to Aidspan that just because Global Fund-supported programs weren’t doing something, it didn’t mean those things were not getting done.

“We are not carrying out assessments [of new arrivals in the IDP camps] because it is not part of our remit; it’s the responsibility of humanitarian actors and the UN High Commissioner for Refugees,” explained malaria program manager Farhana Zuberi in Nairobi in late January for a strategy meeting that gathered all of the stakeholders in the Global Fund architecture in South Sudan.

“But if there is a need to redirect our available resources, we will look at how we can do so.”

Of the six currently active Global Fund grants in South Sudan, one is a malaria grant administered by PSI. Since January 2012, under the grant worth a total of some $38 million, PSI has been consolidating and scaling-up the supply of commodities including long-lasting insecticide-treated nets (LLIN), coordinating stocks of artemisinin combination therapies and providing training and support for health workers in the management and treatment of malaria. The grant was to expire in January 2014 but has been extended until December 2014.

Maintaining the supply chain, both into South Sudan and then to the myriad small dispensaries, clinics and other public facilities around the country, remains a considerable challenge, made worse by the conflict that has completely cut off access to three of the country’s 10 states, and restricted access across the rest of the country.

Warehouse stocks are depleted and their resupply is unlikely in the foreseeable future due to the fighting that blocks the roads or provides a tantalizing opportunity for looting or hijacking of trucks. “The requests from health centers don’t stop,” said Akello Pasquale. “from Nasir, in Upper Nile, or West or Central Equatorial – they all say that they are completely stocked out.” The effects of stock-outs may be pronounced: in Equator region, the malaria prevalence rate is the highest in the country, at 40%.

The sense of urgency is acutely felt against the backdrop of a massive distribution campaign that overcame its own logistic and security challenges, which was in its final stages before the crisis erupted. Over the course of 2013, some 3.7 million LLINs were distributed in seven states. One notable exception: Jonglei, where regular confrontations between Lou Nuer and Murle militias prevented PSI and its partners from carrying out distributions in counties including Pibor, Pochalla and Akobo.

A final push into Unity State was planned for January but has been indefinitely postponed. “We have 348,000 nets ordered and ready to ship to South Sudan; when the national malaria program and the Ministry of Health say that the security situation has improved, and they have a plan in place, we’ll move forward,” said PSI’s deputy director for East Africa, Daun Fest.

Read this article in French. Lire l'article original en français.

[This article was first posted on GFO Live on 18 February 2014.]

To comment on this article, click here.



3. NEWS: Integration of TB and HIV programs in high burden countries both necessary and beneficial, experts say

How to get the two programs working together among anticipated challenges

Forty-one countries will from 2014 be required by the Global Fund to submit joint TB-HIV concept notes under the new funding model in what experts in both fields consider to be necessary and beneficial but also challenging to implement.

The decision by the Global Fund to require countries with high rates of TB-HIV co-infection to submit joint concept notes was announced last October (see article) and reflects the sense that separate programs for TB and HIV in countries with high rates of co-infection was wasting valuable resources. Most of those countries are in sub-Saharan Africa, reflecting the impact of co-infection on the continent. In 2012, the region carried the burden of most of the estimated 1.1 million new TB cases among people living with HIV.

Sobering statistics globally also underscore the need for a more integrated approach to the two diseases. At least one-third of the 35.3 million people living with HIV worldwide are infected with latent TB. They are 20 times more likely to develop active TB than people who are sero-negative, and more likely to die of TB than any other HIV-related illness.

“The public health response to HIV and TB in high burden countries needs to be fully integrated.  Maintaining parallel HIV and TB programs is not an option,” said Luiz Loures, deputy executive director of programs at UNAIDS. “Encouraging and facilitating joint HIV/TB responses has the potential to be a ‘game changer’.”

Integration will be beneficial because it will result in reduced morbidity and mortality and better health outcomes, the experts said, and will lead to improved care for co-infected patients. In addition, integration should produce better epidemiological data.

Cost-savings can be re-invested to produce a stronger response by two groups of researchers, advocates and disease experts who could probably learn a lot from each other.

“There will be challenges, to be sure, but this is something that has to happen,” said Lucica Ditiu, executive secretary of the Stop TB Partnership, in a telephone conversation with Aidspan. “A critical factor will be getting TB and HIV programs to buy into the idea. They must understand that this is the only way to move forward.”

Among the challenges in bringing about integration, the experts said, is that the programs inhabit separate and different worlds. In the pantheon of global health programming and funding priorities, HIV has a higher profile. This will lead to natural, but avoidable, turf wars that will need to be overcome not just by research extolling the virtues of joint programming but a deep and abiding commitment to collaboration.

“This joint concept note process will be great for countries in the long term. There are many economies of scale and synergies to be leveraged,” said Ellen Mitchell of the Netherlands-based TB foundation KNCV.

There are also likely to be some struggles over resource allocation; one scenario that could play out is the overemphasis on key populations at heightened risk for co-infection at the expense of larger populations at risk of only TB.

This will require a robust monitoring and evaluation framework that does more than just combine HIV and TB indicators, the experts cautioned.

Finally, the experts noted that providers of technical assistance may themselves need training in new skills in order to provide relevant, timely and contextual assistance on joint TB-HIV concept notes.

Loures said that UNAIDS will collaborate with other agencies to organize regional workshops that bring together key stakeholders for strategy sessions on how best to fully integrate joint TB-HIV responses.

The full participation of civil society in developing these integrated concept notes is critical, he added. “I see the country dialogue as the central piece to promote and facilitate a much closer collaboration between the HIV and TB communities, but also as a platform to really engage with civil society,” he said.

According to Ditiu, prior to the decision to require joint TB-HIV concept notes, the Global Fund’s HIV disease committee and TB disease committee had established a working group on integration. The working group is developing strategies to make integration a reality in countries with high rates of co-infection. It has developed a draft concept note and will shortly be preparing an information note. In addition to the Global Fund itself, members of the working group are the WHO, UNAIDS, Stop TB and PEPFAR.

“Getting joint concept notes developed will be much easier than implementing joint initiatives,” she said, “but isn’t that true of Global Fund concept notes generally? That’s no reason to shy away from TB-HIV integration.”

A Global Fund FAQ on joint TB-HIV concept notes is available here.

Read this article in French. Lire l'article en français.

[This article was first posted on GFO Live on 18 February 2014.]

To comment on this article, click here.



4. NEWS: Malawi’s CCM adds new TB voices ahead of integrated concept note development

Co-infection is responsible for more than two-thirds of AIDS-related deaths in Malawi

Malawi’s preparations to develop an integrated HIV/TB concept note required under the new funding model have included the election on 12 February of two new members to its country coordination mechanism (CCM) with roots in the TB community.

Malawi had an estimated incidence of co-infection of 16,000 cases in 2012, representing 59% of the number of people in the country living with HIV. Roughly 70% of AIDS-related deaths in the southern African country are attributed to latent TB.

Some $11.2 million in Global Fund grants have been allocated to Malawi’s TB program since January 2009, aiming to pursue DOTS expansion and enhancement, infection control, activities to manage multi drug-resistant TB (MDR-TB) and co-infection with HIV. Thus far 25,000 people have been placed on first-line treatment, which has helped to reduce treatment regimens from 18 to six months.

There remain significant hurdles for the country to bring its TB infections under control, said new CCM member Hastings Banda of Research for Equity and Community Health (REACH Trust).

TB detection rates in Malawi remain low because of a lack of screening and availability of services nationwide, he said, including a lack of reagents to conduct testing at the health facility level.

Low levels of treatment literacy among TB patients means a low level of adherence to drug regimens, which promotes resistance and the spread of MDR-TB.  Among detainees in the prison system, TB infection is especially high because of a lack of consistent screening on intake and routinely during an inmate’s incarceration.

Stigmatization of TB also means that those who are infected are reluctant to seek treatment, Banda said.

Mara Kum’bweza Banda, the chairperson of the National AIDS Commission, says that she hopes that her election to the CCM as a person living both with HIV and TB will help orient the CCM towards the promotion of an integrated approach to the two diseases, while also helping her serve as a role model for other people suffering in silence.

“I would like to encourage people infected with TB to come out and seek treatment as I believe this is the only way that we can fight stigma and build a united front to fight the disease,” she said.

Owen Nyaka is a Key Correspondent for the International HIV/AIDS Alliance.

[This article was first posted on GFO Live on 18 February 2014.]

To comment on this article, click here.



5. NEWS: HIV spreading in Asia, including among Global Fund High Impact countries

Lack of progress raises questions about targeting of HIV response

A UNAIDS special report released in November has warned of a risk that regional progress in Asia and the Pacific in stemming the spread of HIV is stagnating, recommending a closer look at value for money and strategic targets for external and domestic co-financing of prevention, treatment and care activities.

Without a rapid and sustained increase in the size of national budgets devoted to HIV programs and better targeting of resources, specifically in prevention activities, to key affected populations, progress including the 26% reduction in new HIV infections since 2001 could be undermined.

With an estimated 350,000 new cases diagnosed in 2012, the total number of people living with HIV in the region of 38 countries climbed to 4.9 million. Two of those countries have been designated as High Impact by the Global Fund: Pakistan and the Philippines. Trends of new HIV infections are also increasing in Indonesia, also a High Impact country.

The report attributes much of the increase in new infections to highly concentrated epidemics among key populations and within urban environments, and a disasterously low level of knowledge within those populations about testing and diagnosis. Stigma at the institutional level that manifests itself in discriminatory legislation and poverty were also cited as drivers of the increase.

It is in prevention where the gaps in service delivery and activities targeting key populations make themselves known most acutely. According to the report, “only by reaching 80% prevention program coverage among key populations can there be a significant impact on behavior and new infections.”

Investments in targeted interventions for key populations have failed to keep pace with the spread of the virus, according to the report. There are potentially 27 million men who have sex with men who are at risk of infection, yet funding for HIV prevention services specifically targeting that population is meager.

Rising rates of infections in Indonesia, Pakistan, the Philippines and Bangladesh are linked to increasing rates of infections among MSM as well as to increased injected drug use, yet harm reduction, needle exchange and opioid substitution programs are rare.

UNAIDS has recommended community-based interventions as the best approach to respond to the specific needs of each of the key populations at heightened risk of HIV transmission. By implementing a community-based rather than facility-based approach that focuses specifically on key populations and geographic regions with high concentrations of infection, interventions are likely to have a greater impact, according to UNAIDS.

Global Fund-supported programs implementing a community-based approach in service delivery including anti-retroviral treatment as well as prevention activities have achieved considerable success, reaching some 10 million people – denoting the need for wider application of these approaches.

Figures generated in the Fund’s 2012 Progress Report suggest that 560,000 people in Asia in 2011 were on ARVs paid for at least partially by Global Fund grants. Grants have also supported 60 million HIV counseling sessions across the region.

There have, however, been some weaknesses in grant implementation.

A regional HIV grant for South Asia underwent considerable modification to qualify for renewal funding in Phase 2 after poor performance in Phase 1.

The South Asia Regional HIV Program covers Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka, seeking to reduce the impact of HIV on men who have sex with men and transgendered people.

The region was estimated in 2010 to be home to some 4 million MSM, though data collection and analysis has been extremely limited due to the pronounced stigma, discrimination and social exclusion confronting the population.

Program strategies de-emphasizing service delivery in favor of targeted high-impact interventions such as capacity-building and policy dialogue for key populations under a new principal recipient, the UN Development Program’s Asia-Pacific Center, received approval for $10 million.

*Read the article in French. Lire l'article en français.

[This article was first posted on GFO Live on 11 February 2014.]

To comment on this article, click here.



6. NEWS: For its HIV grant, El Salvador chooses sub-recipients representing key populations

El Salvador is an early applicant under the NFM

El Salvador has announced the selection of six sub-recipients (SR) for its $23.1 million HIV grant, marking another step forward on its path towards completing the Global Fund’s processes under the new funding model (NFM).

Six non-governmental organizations were selected by the principal recipient (PR), Plan International, to implement a series of HIV response activities designed to target the most at-risk populations in the Central American country.

According to a 2012 UNAIDS report, HIV prevalence is at 0.6% in El Salvador, but significantly higher among certain key groups, including men who have sex with men, transgender people and commercial sex workers. 

According to a sentinel surveillance study conducted in 2012, sero-prevalence for men who have sex with men is at 10.7%; commercial sex workers, both male and female, have a sero-prevalence rate of 3.14%.

More complete data is expected in 2016, as an integrated bio-behavior (IBBS) study is scheduled to take place in 2015.

The six groups were chosen after an open call for bids by the PR, from 22 applicants. Civil society groups said that the timing of the bid, occurring just 15 days after the open call, may have been too tight for a number of groups to participate and suggested in remarks to Aidspan that the next tender have a longer turn-around time.

Other civil society organizations that work at the grass-roots level have complained that the technical requirements to become eligible to even be considered as a Global Fund SR are too onerous and beyond their technical and managerial capacity.

A technical evaluation committee from the PR shortlisted 10 groups based on an established eligibility criteria and with the technical help of US-based contractor GMS, narrowed the shortlist to the six chosen groups.

The six organizations chosen are:

  • Entre Amigos Association, which works with MSM
  • Alejandría Association, which represents transgender people
  • Aspidh Association, which represents transgender people
  • Orquídeas del Mar, a union of commercial sex workers
  • FUNDASIDA, a national HIV outreach NGO
  • Population Services International’s local arm, PASMO

There has been no announcement about the allocation of the funding for each of the sub-recipients, nor any elaboration of the nature of the activities each organization will be carrying out.

Read this article in Spanish. Lea el articulo en espagnol.

[This article was first posted on GFO Live on 11 February 2014.]

To comment on this article, click here.



7. NEWS: Niger close to procurement plan for malaria response ahead of June rains

The country has received an $18.1 million grant extension as part of transitional funding

Catholic Relief Services, the principal recipient (PR) of Global Fund grants for malaria management in Niger, will expand its slate of services responding to the malaria epidemic, with testing and first-line medication.

The expansion is envisioned under an $18.1-million (EUR 13.5 million) grant extension approved by the Global Fund board in August 2013. The extension was allocated under the transitional funding mechanism that prevents gaps in grant disbursement in countries as the new funding model is rolled-out in place of the previous rounds-based approach.

The order for long-lasting impregnated nets (LLINs) and malaria rapid diagnostic tests (mRDTs) has been  finalized, with the first lot of  nets  expected to arrive between May and June, William Rastetter, the country representative for CRS in Niger, told Aidspan. The order for artemisinin-based combination therapies (ACT) is still under process.

The funds will support the purchase of some 1.65 million LLIN, to be distributed around the Tillabery region in southwestern Niger. The region includes the capital, Niamey, and is the most densely populated region in the arid, malaria-endemic nation. Distribution and associated costs for another nearly 1.2 million nets – which will be purchased separately by the Niger government – for the Dosso region, also in the southwest, is also forecast.

Malaria remains a leading cause of death in Niger, with 3,000 deaths reported from some 2.6 million cases in 2012, according to an August 2013 article in the Lancet.

As PR, CRS has provided LLIN and other outreach services in Niger since 2008; the grant extension marks an expansion into testing and distribution of first-line medication for the organization.

In addition to the LLIN, 4.75 million mRDTs and 1.45 million doses of ACT will be procured. Distribution will be coordinated jointly by CRS and the country's National Malaria Program.

Niger's grant portfolio has undergone a massive restructuring since 2011 after some major weaknesses in procurement procedures emerged during routine verification. Allegations of financial irregularities led to an investigation by the office of the Inspector General (OIG). No report has been issued by the OIG, Rastetter said, but enhanced accountability measures and more stringent fiduciary controls have been applied in order to ensure "good stewardship of [Global Fund] resources".

CRS hopes to conclude its malaria procurement to coincide with the onset of Niger's rainy season, expected in June. However, the order for ACTs is still in process and has been complicated by perceived conflicts in requirements.

Niger's government advocates the use of a particular product because it is familiar to facility-level clinicians, and worries that training on the use of a different product would delay its distribution. Niger was one of eight countries enrolled in the AMFm pilot, which included the introduction of a specific, Global Fund-approved ACT medication for a different PR identified with a green leaf on the packaging. With the end of the pilot in 2012, the product may no longer be available.

*Read the article in French. Lire l'article en français.

[This article was first posted on GFO Live on 17 February 2014.]

To comment on this article, click here.



8. NEWS: Anti-gay bill in Uganda could have disastrous public health implications

Bill would exacerbate stigma, exclusion and increase risk of HIV infection, activists and researchers warn

Public health program managers and activists, many of whom receive support from the Global Fund, have warned of potentially catastrophic consequences for reducing Uganda's HIV infection rate should President Yoweri Museveni follow through on a plan announced on 14 February to sign into law a repressive bill effectively banning homosexuality.

The Anti Homosexuality Bill was passed by parliament in December. Earlier versions of the bill would have imposed the death penalty on individuals found guilty of ‘aggravated homosexuality’; that penalty, in the version before Museveni, was changed to life in prison.

Most worrisome to those who are implementing the more than $130 million in activities funded by Global Fund grants are the terms of the bill that threaten harsh penalties for those who would promote or aid and abet homosexuality: a category that could include government- and externally funded programs providing essential services for men who have sex with men and other key populations.

Dozens of Ugandan and international clinicians, researchers and academics signed a letter dated 6 February encouraging that Museveni veto the bill, arguing that not only did it violate the national constitution to protect the freedoms of all Ugandans but also contradicted scientific evidence.

Further, the letter, which bore among others the signature of the UN Special Envoy on AIDS in Africa, who is also the former vice president of Uganda, Dr Sepciosa Wandira Kazibwe, argued that the bill would “further exacerbate the marginalization, discrimination and exclusion of people known to be, or suspected of being homosexual,” meaning they would be less able to access health services and thus more at risk of infection or of infecting other people with HIV and other sexually transmitted diseases.

HIV prevalence among men who have sex with men is estimated at 13%: more than three times the average prevalence among men who have sex exclusively with women (4.1%) and nearly twice the national generalized prevalence of 7.3%.

Uganda has also experienced a steady rise in HIV incidence since 2005, despite widely acclaimed early success in anti-retroviral treatment and prevention of mother-to-child transmission.

The bill will also provide cover – based on a presupposed fear or institutionalized stigma – for health workers to discriminate in the provision of medical services to members of the LGBT community.

The bill’s passage into law is likely to have significant direct implications for both outreach activities and service delivery supported by the Global Fund.

It is also likely to eviscerate any progress made in implementing a Key Affected Populations pilot program in Uganda. This pilot, funded by the Global Fund Secretariat, is designed to strengthen engagement of men who have sex with men, sex workers, fishing communities and other key populations in shaping the 2014 HIV concept note under the new funding model. The pilot is also designed to strengthen representation of, and accountability to, key affected populations on Uganda’s country coordination mechanism.

[This article was first posted on GFO Live on 18 February 2014.]

To comment on this article, click here.



The following articles have been posted on GFO Live on the Aidspan website. Click on an article heading to view the article. These articles may or may not be reproduced in GFO Newsletter.

NEWS : Le Rwanda et le Fonds mondial s’engagent dans un projet pilote de financement axé sur les résultats

Le Rwanda et le Fonds mondial ont annoncé le 10 février, dans le cadre de leurs négociations pour la reprogrammation de la Phase 2 d'une subvention de lutte contre le VIH (RWN-H-MOH), qu’ils mettront à l’essai un nouveau modèle de financement axé sur les résultats (‘results-based financing’ ou ‘RBF’ en anglais).  Cette approche vise à encourager plus de flexibilité et rationaliser le financement des pays dotés des meilleures capacités.

NEWS : Rwanda and Global Fund sign a pilot results-based financing model

The signing of a results-based financing model in Rwanda marks a new approach for the Global Fund to a more hands-off approach to funding strong partners. The model will provide budget support to the national strategy while rewarding good performance against national targets.

NEWS : Zambia and Swaziland develop advocacy roadmap to promote behavior change as central to Global Fund proposals

Zambia and Swaziland have developed an advocacy roadmap to ensure effective implementation of Global Fund grants and have focused on behavior change as a major priority.


This is issue 237 of the GLOBAL FUND OBSERVER (GFO) Newsletter.

We welcome suggestions for topics we could cover in GFO. If you have a suggestion, please send it to the Editor of GFO (see contact information below).

Author: Author: Articles 1 and 2: Stephanie Braquehais. Article 3: David Garmaise (, Aidspan’s Senior Analyst. Article 4: Owen Nyaka. Article 5: Kerstin Reisdorf. Article 6: Pablo Anamaria. Article 7: Agnes Tandler (Aidspan correspondents). Article 8: Lauren Gelfand (, Aidspan’s Editor-in-Chief.

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Aidspan Executive Director: Kate Macintyre (

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